Print Inspection: RL014300

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure weekly progress was noted until a change of condition resolved for 1 of 2 sampled residents (# 2) who experienced changes of condition that required monitoring. Findings include, but are not limited to: Resident 2 was admitted to the facility in 06/2024 with diagnoses including Parkinson’s disease and dementia. The resident’s 06/15/26 through 09/21/26 clinical record was reviewed, and interviews with staff were conducted. The following was identified: * On 06/19/26 a “Nurse note” was completed following the resident’s return from the hospital due to a fall on 06/15/26. The nurse noted “some scattered bruises” on the left upper arm, elbow, and lower forearm. In addition, the Weekly Pressure Injury Report used by the nurse to document skin conditions also noted bruising to the right forearm and elbow on 06/19/26. On 06/27/26 the nurse documented the bruising “on [his/her] arms has healed” and noted some slight discoloration on the right arm was still present and discontinued “skins for bruising.” No additional skin monitoring by the nurse was completed for the bruising still noted on the right arm. Observation notes on 06/30/26 by MTs documented “some bruising healing on [his/her] right arm; on 07/09/26 documentation indicated “no signs of bruising”; and on 07/22/26 documentation noted “bruise is healing/fading.” There was no documentation of the progress of the skin condition after 07/23/26, when a MT documented “bruise is healing, its [sic] greenish/yellow . . .” * On 06/27/26 the resident was noted to have a “red rash” in the groin area. On 07/11/26 the nurse documented on the Weekly Pressure Injury Report “rash on groin slightly pink, very light,” and discontinued monitoring of the rash. On 07/17/26 an LPN note indicated “Resident groin enflamed, possibly moisture related.” There was no documentation of the progress of the skin condition following the nurse’s note on 07/17/26. * On 09/09/26 the resident was put on alert charting for bruising on his/her right toe and right wrist. There was no documented evidence the bruise to the right wrist was monitored, with progress noted at least weekly until resolution. In an interview on 09/24/26 at 11:35 am, Staff 3 (RN/Health and Wellness Director) acknowledged the right wrist was not monitored and her process for skin monitoring had not been to monitor the bruises until they were completely gone. The need to ensure the facility documented monitoring of changes of condition at least weekly until resolved was reviewed with Staff 1 (General Manager), Staff 3, and Staff 12 (Corporate RN) on 09/24/26 at 2:00 pm. They acknowledged skin monitoring had not been completed and documented weekly until the condition resolved.

1) Action taken - The clinical team has reviewed Resident #2’s record to confirm each cited skin concern, including bruising and rash, is documented as resolved or as a new baseline. Active conditions will receive resident-specific interventions and monitoring until resolved or established as a new baseline. 2) System correction - Memory Care Staff have completed training related to monitoring and documenting resident changes of condition. Reportable conditions will generate incident reports and Temporary Service plans/Observations that will be reviewed by the MCA/RN. Temporary service plans will include instruction for staff on what to monitor and facility designee/RN will document resolution of incident. Staff will ensure that the RN is notified of any changes in residents needs, RN will complete Change in Condition assessments, monitoring and service plans are updated as needed. The facility will review documentation in the clinical meeting (observation notes, skin/shower notes) to identify and respond to all skin changes. The facility will use the clinical whiteboard to track active changes of condition and support clinical follow-through. 3) Evaluation - The GM and MCA or Designee will review incident reports and significant changes of condition within 24-28 hours. Weekly meeting with GM and RN will be used to audit Change of Condition assessments and their completion 4) Ongoing Monitoring Responsibility - The GM, MCA and RN are responsible to see that the corrections are completed/monitored.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to have a system in place to accurately track controlled substances administered by the facility for 1 of 1 sampled resident (# 4) whose MAR and controlled substance disposition logs were reviewed. Findings include, but are not limited to: Resident 4 moved into the facility in 10/2025 with a diagnosis of scoliosis. Resident 4's controlled substance disposition log and 09/01/26 to 09/22/26 MAR were reviewed. The following was identified: * Resident 4 had signed physician orders for Morphine sulfate 20 mg/ml solution, 0.25 ml every four hours scheduled and 0.25 ml every 60 minutes for pain or breathing challenges as needed. * On 09/23/26 at 10:30 am, a comparison of the morphine bottles to the disposition log showed the amount of medication left in one of the bottles was not reflected accurately on the log. Staff 13 (MT) indicated there were two bottles of morphine staff used to administer the PRN and scheduled morphine and it was noted on the disposition log if the medication was given as a PRN or scheduled. The amount in one of the two bottles observed did not match the amount on the corresponding disposition log. Staff 13 acknowledged the bottle showed “about 27.75 ml” and the disposition log indicated 28.75 ml remaining. On 09/23/26 at 12:48 pm, Staff 3 (RN/Health and Wellness Director) confirmed the bottle amount did not match the disposition log and stated she would investigate. She acknowledged the discrepancy should have been identified at shift change. Inconsistencies between Resident 4’s morphine sulfate medication bottle and Controlled Substance Disposition logs and the need to ensure the facility had an effective system for tracking controlled substances was discussed with Staff 1 (General Manager), Staff 3, and Staff 12 (Corporate RN) on 09/24/26 at 2:00 pm. They acknowledged the findings.

1.Action Taken - The Health & Wellness Director has reviewed the controlled substance records for Resident #4 and verified that the current inventory record accurately reflects the controlled substances on hand. The morphine count discrepancy identified during the survey has been investigated and reconciled. Medication technicians and licensed nurses are re-educated on accurate controlled substance documentation, two-person inventory counts at shift change, recount procedures and immediate reporting of discrepancies. 2.System correction - Staff have been retrained to follow company policy relation Medication Services – specifically related to control of Narcotics. If there is a discrepancy in the initial count, the same team will do an immediate recount of the medication(s) in question. If the recount number is inconsistent with the original count, the same team will do another recount of the medication(s) to verify which count was correct. If the count is determined to be off, or if recount results are inconsistent, a supervisor from the H&W team and/or General Manager will be notified immediately and a new two (2) person team will count the medication(s) in question and Incident report will be completed to document the findings. 3. Evaluation - The Health & Wellness Director will routinely review controlled substance records, and the RN and GM will participate in audit of narcotics Reconciliations log at least twice per month per company policy. 3. Ongoing Monitoring Responsibility - The Health & Wellness Director will be responsible for implementing and monitoring the corrective actions. The General Manager will be ultimately responsible for ensuring the corrections are completed and ongoing compliance is maintained.

OAR 411-054-0037 (1a)(2) Acuity Based Staffing Tool - Elements (1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING. Facilities must select and implement a Department-approved Acuity-Based Staffing Tool (ABST) for determining appropriate staffing levels. Individual resident needs and care elements must be the primary consideration when developing and maintaining an ABST. Regardless of the ABST adopted, all requirements set forth in this rule and OAR 411-054-0034 (Resident Move-in Evaluation) must be met. Facilities shall: (a) Select and implement the Department’s developed ABST or submit a proprietary ABST to the Department for approval as outlined in paragraph (2) of this rule. (2) PROPRIETARY ABST. A facility that chooses to use a proprietary ABST must implement a Department-approved ABST that meets this rule. (a) REQUIRED ELEMENTS. The proprietary ABST the facility adopts must meet the following requirements: (A) Facilities can group or combine ABST care elements in their ABST reports, however each resident’s ABST evaluation must individually address and document all ABST care elements outlined in paragraph (3) of this rule. (B) When calculating total time, the ABST must include the care elements for each resident and staff time needed to complete each individual care element. (C) Ensure the ABST can produce a report that identifies all residents currently residing in the facility, the care elements for each of the residents, and the staff time required to complete the care elements for each resident. (D) ABST total time must present in minutes per shift, per day. If the proprietary ABST does not have this functionality, at a minimum the ABST total time must present in daily minutes. If a Proprietary ABST presents total time in daily minutes the facility’s ABST policy must describe how staffing per shift is determined. (E) Identify the date the resident’s ABST evaluation was last completed. (F) If applicable, determine ABST time for both residents on a Specific Needs Contract and residents not on a Specific Needs Contract to build posted staffing plans as outlined in this rule. (b) PROPRIETARY ABST REVIEW REQUEST. If a facility proposes to use a proprietary ABST, the facility must submit the Proprietary ABST ODHS Review Request form (se528132), including but not limited to the following: (A) Facilities who want to implement or switch to a proprietary ABST must submit Proprietary ABST ODHS Review Request form (se528132) prior to implementation. (B) Sample ABST report displaying the ABST care elements, and the staff time needed to complete the displayed care elements, with a total time in minutes shown per shift, per day. If the proprietary ABST only provides total time in daily minutes, the facility’s ABST policy must describe how staffing per shift is determined. (C) The facility’s ABST policy required under OAR 411-054- 0025(7)(i). (c) ABST SUMMARY STATEMENT. If the proprietary review request is approved, a facility must develop and maintain an ABST Summary Statement that meets the requirements, as outlined in the Proprietary ABST ODHS Review Request form (se528132). This includes providing a general guide explaining how the ABST functions. The summary statement must be available upon request by the Department. (d) DEPARTMENT REVIEW OF PROPOSED PROPRIETARY ABST REQUEST. The Department will review and either approve or deny the facility’s proprietary ABST. The Department may request additional documentation, potentially including a virtual demonstration, to make the determination. If the ABST is deemed to not meet this rule, the Department may deny or rescind approval at any time. The Department shall provide the facility with a written explanation of the reasons for the denial or decision to rescind approval. If a facility appeals a decision to rescind, the facility may continue to use the facility’s existing proprietary ABST until a final order has been issued. (e) APPEALS PROCESS. The Department will determine whether to approve or deny the request. If the proprietary ABST is denied or rescinded, the facility is entitled to a contested case hearing pursuant to ORS chapter 183. Prior to a contested case hearing, the facility may request an informal conference. (f) ANNUAL STATEMENT. Once approved, the facility must provide the Department an annual statement attesting no substantive changes have occurred to the design of the facility’s proprietary ABST that impacts its functionality. The facility must submit statements to the Department every year, between January 1 and March 31. (g) If the facility makes substantive changes to the proprietary ABST design, and if those changes impact ABST functionality making the prior submitted information inaccurate or invalid, then the facility must re-submit to the Department the Proprietary ABST ODHS Review Request Form (se528132) as described in this rule for review prior to implementing the new or revised ABST. (3) ABST CARE ELEMENTS. The required ABST care elements include activities of daily living and other tasks related to resident care and services, as outlined in OAR 411-054-0030, 411-054-0034, and 411-057- 0160. If any individual care element requires more than one staff, additional time must be accounted for as described in OAR 411-054-0070(1). The ABST must individually address and document the care time required to complete each of the following individual ABST care elements: (a) Personal hygiene. (b) Grooming. (c) Dressing and undressing. (d) Toileting, bowel, and bladder management. (e) Bathing. (f) Transfers. (g) Repositioning. (h) Ambulation. (i) Supervising, cueing, or supporting while eating. (j) Medication administration. (k) Providing non-drug interventions for pain management. (l) Providing treatments. (m) Cueing or redirecting due to cognitive impairment or dementia. (n) Ensuring non-drug interventions for behaviors. (o) Assisting with leisure activities, assist with social and recreational activities. (p) Monitoring physical conditions or symptoms. (q) Monitoring behavioral conditions or symptoms. (r) Assisting with communication, assistive devices for hearing, vision, and speech. (s) Responding to call lights. (t) Safety checks, fall prevention (u) Completing resident specific housekeeping or laundry services performed by care staff. (v) Providing additional care services. If additional services are not provided, this element can be omitted. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to: The facility's proprietary ABST was reviewed with Staff 1 (General Manager) and Witness 1 (RN Consultant) 09/23/26 at 9:45 am.. There was no documented evidence each of the 22 required care elements were addressed in the ABST, including: * Responding to call lights; * Providing non-drug interventions for pain management; * Providing treatment; * Cueing, redirection for cognitive impairments; and * Providing non-drug interventions for behaviors. On 09/23/26 at 2:50 pm, Staff 1 confirmed the proprietary ABST did not include each of the required care elements and the facility was not capturing staff time needed for residents who required assistance in these areas. The need to ensure the ABST individually addressed and documented each of the 22 required care elements was discussed with Staff 1, Staff 3 (RN/Wellness Director), and Staff 12 (Corporate RN) on 09/24/26 at 1:35 pm. They acknowledged the findings.

1) Action Taken The Health & Wellness Director and General Manager reviewed the community's Acuity Based Staffing Tool (ABST) in accordance with Leisure Care Policy. The review identified that five required care elements were not populating from the EHR into the ABST. The vendor corrected the system issue, and the community verified that all required ABST care elements that were missing (• Call lights, Non-drug pain interventions, Treatments , Cueing/redirection and Non-drug behavioral interventions) were accurately represented within the ABST. Resident ABST evaluations were reviewed and updated as necessary to ensure scheduled and unscheduled care needs were accurately reflected and the staffing plan aligned with ABST results. 2) System Correction In accordance with Leisure Care Policy, the Health & Wellness Director will verify that all required ABST care elements are accurately populating following any EHR update, system modification, or software enhancement. ABST evaluations will be completed upon admission, with significant changes in condition, with service plan updates, and at least quarterly. Resident scheduled and unscheduled care needs will be included in the ABST and the staffing plan will be reconciled to ABST results to ensure staffing levels meet resident needs. Documentation of ABST validations, staffing plan reviews, and corrective actions will be maintained. 3) Monitoring / Evaluation The Health & Wellness Director will review ABST reports weekly to verify required care elements continue to populate correctly and resident care needs are accurately reflected. Any discrepancies will be corrected immediately. During weekly meetings, the General Manager and Health & Wellness Director will review ABST validation findings, staffing plan reconciliation, and supporting documentation to ensure ongoing compliance with ABST requirements. Documentation of monitoring activities will be maintained for survey review. 4) Ongoing Compliance Responsibility The General Manager and Health & Wellness Director are responsible for ensuring ongoing compliance with Leisure Care, maintaining accurate ABST evaluations, verifying staffing plans align with ABST results, and ensuring required documentation is completed and retained.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills at least every other month according to the Oregon Fire Code (OFC) and provide fire and life safety instruction to staff on alternate months from fire drills. Findings include, but are not limited to: Six months of fire and life safety records, from 03/2026 through 09/2026, were reviewed with Staff 1 (General Manager) on 09/22/26 at 2:25 pm. The following was identified: a. The facility lacked documented evidence unannounced fire drills were conducted at least every other month and fire drills records included the following: * Escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. b. The facility lacked documented evidence fire and life safety instruction was provided to staff at least every other month on alternate months from fire drills. The need to ensure fire drills were conducted at least every other month in accordance with the OFC and that fire and life safety instruction was provided to staff on alternate months from fire drills was discussed with Staff 1, Staff 3 (RN/Health and Wellness Director), and Staff 12 (Corporate RN) on 09/24/26 at 1:35 pm. They acknowledged the findings.

1) Action Taken In accordance with Leisure Care Life Safety policies and OAR 411-054-0090, the General Manager and Plant Operations Supervisor reviewed the Memory Care fire drill process and documentation practices. The fire drill documentation form was revised to include all required regulatory elements not previously captured, including: • Escape route(s) used during the drill • Number of occupants evacuated • Problems encountered during the drill • Residents who resisted, refused, or were unable to participate • Evaluation of the drill, including opportunities for improvement • Staff response and performance during the drill A fire drill schedule was established to ensure Memory Care fire drills are conducted every other month as required. The General Manager and Plant Operations Supervisor were educated on the revised documentation requirements and fire drill schedule. 2) System Correction In accordance with Leisure Care policy and OAR 411-054-0090, all Memory Care fire drills will be conducted and documented using the company Fire Drill Report. The Fire Drill Report will include the date and time of the drill, shift conducted, escape route utilized, number of occupants evacuated, resident participation, problems encountered, staff response, drill evaluation findings, and any corrective actions identified. Fire and life safety instruction will be provided to staff during fire and monthly all staff meeting. Attendance and training content will be documented and maintained for survey review. The Plant Operations Supervisor will maintain a fire drill schedule to ensure drills occur at the required frequency and documentation is completed immediately following each drill. Fire drill records will be maintained and available for survey review. 3) Monitoring / Evaluation The General Manager and Plant Operations Supervisor will review fire drill requirements prior to each scheduled drill and review completed Fire Drill Reports during their weekly 1:1 meetings to verify all required documentation elements are completed and any identified opportunities for improvement have been addressed. Any missing documentation or identified concerns will be corrected immediately and documented as part of the fire drill review process. 4) Ongoing Compliance Responsibility The General Manager is responsible for ensuring ongoing compliance with Leisure Care fire drill policies and regulatory requirements, including completion of required drills, review of documentation, and ongoing monitoring. The Plant Operations Supervisor is responsible for conducting, documenting, and maintaining fire drill records in accordance with company policy and OAR requirements

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure each resident was re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to: Six months of fire and life safety records, from 03/2026 through 09/2026, were reviewed with Staff 1 (General Manager) on 09/22/26 at 2:25 pm. The facility did not provide evidence residents were reinstructed on fire and life safety topics at least annually. The need to re-instruct residents at least annually on fire and life safety topics was discussed with Staff 1, Staff 3 (RN/Health and Wellness Director), and Staff 12 (Corporate RN) on 09/24/26 at 1:35 pm. They acknowledged the findings.

1) Action Taken In accordance with Leisure Care Life Safety policies, the General Manager and Opal Manager developed a resident fire and life safety education program for the Memory Care community. Current residents have received fire and life safety instruction, including what to do if a fire alarm activates, basic fire extinguisher awareness, fire extinguisher locations, and the principles of RACE (Rescue, Alarm, Confine, Extinguish/Evacuate) and PASS (Pull, Aim, Squeeze, Sweep). Resident participation and educational content have been documented. A tracking system was established to monitor completion of resident fire and life safety education, and documentation is maintained in the Fire and Life Safety Compliance Binder. 2) System Correction In accordance with Leisure Care Life Safety policies, resident fire and life safety education will be incorporated into the monthly Memory Care activity calendar to ensure ongoing compliance. New residents will receive fire and life safety instruction upon admission or within 24 hours when appropriate, and annual re-instruction will be tracked through the compliance binder. Educational sessions will include fire alarm response procedures, evacuation awareness, fire extinguisher purpose and location, and review of RACE and PASS principles. Attendance and training documentation will be maintained in the Fire and Life Safety Compliance Binder and available for review. 3) Monitoring / Evaluation The General Manager, Plant Operations Supervisor, and Opal Manager will review the Fire and Life Safety Compliance Binder during weekly leadership meetings to verify resident education sessions have been completed, attendance has been documented, and required training topics have been addressed. Any identified omissions will be corrected promptly. 4) Ongoing Compliance Responsibility The General Manager is responsible for ensuring ongoing compliance with resident fire and life safety education requirements. The Opal Manager is responsible for scheduling, conducting, and documenting monthly resident education sessions. The Plant Operations Supervisor is responsible for supporting the program and monitoring documentation to ensure compliance is maintained.

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training ? Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS? RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident?s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual?s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 1 of 4 sampled newly hired staff (# 10) whose training records were reviewed. Findings include, but are not limited to: Refer to Z155.

Refer to Z155

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C361, C420, and C422.

Referral tag, please see C361, C420, and C422.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired staff (#s 9 and 10) completed all required pre-service orientation training topics and 3 of 3 newly hired direct care staff (#s 7, 8, and 9) completed all required pre-service dementia training topics. Findings include, but are not limited to: Staff training records were reviewed on 09/23/26 at 9:00 am with Staff 2 (Business Office Manager). The following was identified: a. There was no documented evidence Staff 9 (MT) and Staff 10 (Housekeeper), hired 07/21/26 and 05/27/26, respectively, had completed one or more of the following pre-service orientation topics before completing any job duties: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Food handler’s certificate; * Infectious disease prevention; * HCBS course; * LGBTQIA2S+ course; * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of a person-centered approach. b. There was no documented evidence Staff 7(CG), hired 05/18/26, Staff 8 (CG), hired 05/27/26, and Staff 9 completed one or more of the following pre-service dementia training topics for direct care staff prior to providing personal care: * Environmental factors that are important to a resident’s well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; and * Use of supportive devices with restraining qualities in memory care communities. The facility’s need to ensure all training was completed within the required timeframes was discussed with Staff 1 (General Manager), Staff 3 (RN/Health and Wellness Director), and Staff 12 (Corporate RN) on 09/24/26 at 2:00 pm. They acknowledged the findings.

Z155 1) What actions will be taken to correct the rule violation? The Business Office Manager and hiring manager/supervisor will review the employee training records identified during the survey and verify completion of all required pre-service orientation and training requirements. The community will review and revise the employee training tracking system to ensure all required pre-service orientation and training requirements identified during the survey are included. The Business Office Manager and hiring manager/supervisor will review the revised tracking process and required pre-service training elements to ensure onboarding requirements are completed and documented. 2) How will the system be corrected so this violation will not happen again? The Business Office Manager will maintain the employee training tracking system and monitor completion of all required pre-service orientation and training requirements. Hiring managers/supervisors will be responsible for ensuring newly hired employees complete required training prior to independently performing job duties. The employee training tracking system will be used during onboarding to verify completion of all required pre-service training elements and supporting documentation. The Business Office Manager and hiring manager/supervisor will review onboarding requirements for each newly hired employee to ensure all required pre-service training elements have been completed and documented before the employee independently performs job duties. 3) How will the area needing correction be evaluated? The Business Office Manager will review employee onboarding records and the employee training tracking system to verify completion and documentation of required pre-service training requirements. Upon verification that required pre-service training has been completed, the Business Office Manager will communicate with the hiring manager/supervisor that the employee may independently perform job duties. The General Manager will periodically review onboarding and training records to verify compliance with pre-service training requirements. Compliance will also be evaluated through the annual Risk Management audit process, which includes review of employee training records and onboarding documentation. 4) Who will be responsible to see that the corrections are completed/monitored? The Business Office Manager and hiring managers/supervisors will be responsible for implementing and monitoring the corrective actions. The General Manager will be ultimately responsible for ensuring the corrections are completed and ongoing compliance is maintained.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C270 and C302.

Refer to C270 and C302